Section XI: Chronic Pain After Injury

Alternative Methods for Managing Pain

Goals of the Exercise

1. Develop nonpharmacological pain management skills.

2. Alleviate pain to a degree that allows a return to previous level of social and occupational functioning.

3. Increase aerobic and anaerobic fitness.

4. Accept that some level of pain and limitations may be lifelong.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Alternative Methods for Managing Pain” activity is intended to provide veterans/ service members suffering from severe and/or chronic pain with alternatives to the use of potentially addictive medications to manage that pain. The exercise offers several alternative approaches to managing pain and restoring quality of life without running the risk of addiction or a relapse which may accompany either use of traditional pain medications or trying to “gut it out” and cope with pain through willpower, risking relapse via self-medication. Follow-up may include assignments to investigate local service providers or support groups, as well as investigation of online resources including the support groups identified in the handout; bibliotherapy using books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner, and/or films suggested for the topics of “Chronic Illness and Disabilities” and “Substance Abuse” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, also published by John Wiley & Sons.

EXERCISE XI.A Alternative Methods for Managing Pain

If you suffer from severe or chronic pain but are concerned about addiction and need ways to manage pain other than narcotic pain medications, this exercise will help you find some ways.

1. How does the chronic pain you experience affect your daily life?

_____

_____

2. Please identify any professionals with whom you're working to manage your pain.

_____

_____

Do those professionals know of your concerns about addiction? Are they experienced and qualified in working with people who suffer from addictions? _____

3. What other methods of pain management have you tried, and what worked best for you?

_____

_____

4. Here are some nonaddictive ways of managing pain. Please talk with your doctor and your therapist about each of these approaches, investigate whatever opportunities your community offers you to try, and briefly write about what you find.

a. Over-the-counter (OTC) pain medications. These are relatively mild pain-relieving drugs with no mind-altering effects. The most common are aspirin, ibuprofen, naproxen, and acetaminophen, all of which go by various brand names. All of these except acetaminophen are classified as non-steroidal anti-inflammatory drugs, or NSAIDs. If you use these medications, be careful not to exceed safe dosages. Excessive amounts can damage the stomach lining, liver, and kidneys, and in extreme cases cause death. Other pain-relieving medications stop the pain of acid reflux and heartburn (and also lower your risk for cancer of the esophagus.)

b. Other non-mind-altering medications. This category includes medications for joint pain called glucosamine chondroitin and MSM. They help the body's natural healing processes rebuild damaged cartilage and connective tissues.

c. Topical (external) medications. These are ointments that can provide relief for pain from musculoskeletal problems including arthritis and joint injuries. They include pain-relieving ingredients, and some also have anti-inflammatory ingredients which reduce swelling and soreness. Some contain steroid compounds, and some contain capsaicin, the same chemical that makes pepper spray burn. You should check with your doctor before using these medications.

d. Diet modifications. Sometimes pain is caused by unhealthy elements or deficiencies in a person's diet. Other problems may be due to food allergies—these can cause heartburn, headaches, rashes, and other problems. As part of a medical workup, you should get an allergy screening. You may want to work with a dietician or nutritionist.

e. Acupuncture. Acupuncture has been proven to give fast and effective relief of pain in many cases. If you use acupuncture, work only with a qualified professional.

f. Therapeutic massage. This is another technique that, provided by trained professionals, can give quick and lasting relief for many cases of chronic musculoskeletal pain.

g. Hypnosis. This is very effective for many people—as with other types of treatment, be sure to work with a professional with the right training, credentials, and experience.

h. Meditation. Many pain sufferers find that meditation, especially guided imagery, can help them detach from their pain. Soothing music can increase the effectiveness of meditation and people undergoing surgery respond better to anesthesia and recover more quickly afterward if they listen to soothing music before, during, and after surgery.

i. Stretching and progressive muscle relaxation. Be careful not to push the stretch too far and cause more pain or injury. This is good for back and neck pain and headaches.

j. Moderate cardiovascular exercise. If you can exercise, 20 to 30 minutes of moderate cardio workout (enough to make you sweat, but not to cause shortness of breath) will relieve your pain by increasing the brain's levels of neurotransmitters that act as natural pain relievers. Before you start an exercise program, talk with your doctor to make sure it's safe and to ask how to get the most benefit from your workouts.

k. Laughter. Hearty or prolonged laughter boosts levels of the same neurotransmitters as cardiovascular exercise, and affects pain and emotional distress the same way. Laughter also strengthens your immune system, improving your resistance to illness.

l. Pet therapy. Spending time with an affectionate animal also provides some relief from physical and emotional distress. Hospitals often include pet therapy in treatment.

m. Spiritual and/or religious activity. Many find comfort in prayer and the company of others who share their spiritual beliefs. This can reduce the isolation that often comes with intense pain and help people make sense of an experience that seems senseless.

n. Pain management support groups. You may find advice and support in these groups. They may be listed in local newspapers or magazines, and hospitals often have groups. You may find one by checking there. There are also pain management groups online. You can find current information via the Internet. Some active sites as of summer 2010 are:

American Chronic Pain Association: www.theacpa.org

Back Pain Support Group: www.backpainsupportgroup.com

Chronic Pain Support Group: www.chronicpainsupport.org

National Chronic Pain Outreach Association, Inc.: www.chronicpain.org

Which of these are available for you?

5. Briefly describe your plan to cope with pain using nonaddictive methods:

_____

_____

_____

Be sure to bring this handout back to your next therapy session, and be prepared to discuss your thoughts and feelings about the exercise.

Coping with Addiction and Chronic Pain

Goals of the Exercise

1. Alleviate pain to a degree that allows a return to previous levels of social and occupational functioning.

2. Follow through with medical recommendations.

3. Take medication as prescribed.

4. Strengthen support network.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Coping with Addiction and Chronic Pain” activity is designed for use with veterans/service members who, as the title indicates, suffer from both addiction and severe and persistent pain. It addresses the perceived dilemma many pain sufferers face of reconciling participation in 12-Step recovery programs with the need to use prescribed medications that have a high potential for addiction, as well as noting other sources of emotional and practical support. It is helpful for the psychotherapist to coordinate work on this issue with any other health care providers from whom the veteran/service member is receiving services, after ensuring that you and the other providers have each received the veteran's/service member's consent to share treatment information. Follow-up or concurrent treatment activities can include referral to one or more of the chronic pain support groups cited in the exercise and bibliotherapy using one or more of the books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy using films on the topic of “Chronic Illness and Disabilities” recommended in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, also published by John Wiley & Sons.

EXERCISE XI.B Coping with Addiction and Chronic Pain

Some people suffer from both substance abuse problems and chronic pain. This puts them in a dilemma, as normal treatments for pain use narcotics or other strong drugs with potential for addiction. Often, the pain may be what led these people to begin using addictive drugs. On the other hand, some doctors are reluctant to prescribe these drugs, for fear of their patients getting addicted. Either way, you need to achieve and maintain a life free of both addiction and ongoing pain. Fortunately, there are solutions. This exercise will help you find some of those solutions.

1. How does chronic pain impact your daily life? Describe the relationship between your problems with alcohol or other drugs and with pain management.

_____

_____

_____

2. Do your medical providers specialize in pain management and addiction? If not, can they give you a referral to a pain management specialist? As part of this exercise, please check on this and let your therapist know. Also, have you told them about your addiction history? If not, what keeps you from sharing that information?

_____

_____

3. In recent years the medical profession has found that even drugs that are usually highly addictive do not result in addiction for pain patients if they take no more than is needed, and for no longer than needed, to control the pain. If you and your doctor plan to manage your pain this way, how will you avoid taking more than you need and switch to something safer and not so strong as soon as appropriate, to avoid getting hooked?

_____

_____

4. Another fact about pain medications: When they are taken before pain gets severe, it takes less to block the pain and keep the patient comfortable. This is why hospitals sometimes give people their pain medications on a regular schedule even when they aren't too uncomfortable. How do you feel about the idea of taking pain medications on a schedule?

_____

_____

_____

5. Many alcoholics and other addicts have found that when they used narcotics or equivalent drugs, even if they didn't get addicted to those drugs, their judgment and inhibitions were affected, and they relapsed into drinking or using other drugs. How will you avoid this trap?

_____

_____

6. Medical professionals have a central part in pain treatment, but other people also have key roles to play in helping you manage this situation (e.g., your recovery sponsor, family, and friends). How can they help you avoid falling into addictive thinking and behaviors when you're using potentially habit-forming drugs to manage your pain?

_____

_____

7. If you are participating in a 12-Step program, you need to know your program's philosophy about the use of prescribed medications. The position of Alcoholics Anonymous is that if your doctor knows your history and is experienced working with people with addictions, and you're taking the medications as prescribed, you're doing what you need to do to stay sober. Other programs have similar views. If others in your group challenge this, they don't know their program well enough. If you have questions, check the official literature. Do you know others in 12-Step programs that have had to take powerful prescribed medications? How have they avoided falling into the trap of substance abuse?

_____

_____

8. In addition to 12-Step or other recovery programs focused on addictions, you may find help from support groups specifically for chronic pain, either local groups which you may be able to find through local media (many newspapers publish lists of support groups of all kinds) or online groups like the following (these are current in mid-2010, but with time these sites may disappear and others appear—for current info, use an Internet search engine).

a. American Chronic Pain Association: www.theacpa.org

b. Back Pain Support Group: www.backpainsupportgroup.com

c. Chronic Pain Support Group: www.chronicpainsupport.org

d. National Chronic Pain Outreach Association, Inc.: www.chronicpain.org

9. Have you had any contact with any of these or other groups, either local or online? If so, please identify the groups and a brief note about your experience with each. If not, please look into them and talk with your therapist about what you learn.

_____

_____

_____

10. Please list the methods and resources you will use to cope with addiction and chronic pain.

_____

_____

_____

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.

Helping Myself By Helping Others

Goals of the Exercise

1. Alleviate pain and allow a return to previous levels of functioning.

2. Resolve any negative feelings about the injury responsible for the pain.

3. Develop an understanding that thoughts and behaviors affect the pain experience.

4. Describe ways to take an active role in pain control.

5. Strengthen support network.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Helping Myself by Helping Others” activity is designed for veterans/service members at greater risk of unhealthy patterns of isolation and brooding or self-pity, or those with strong religious or spiritual beliefs. It is based on studies of the beneficial effects of altruism ranging from Victor Frankl's Man's Search for Meaning to the more recent work of Paul Pearsall (The Pleasure Prescription, 1996), Larry Dossey (Meaning & Medicine, 1991), and Allan Luks and Peggy Payne (The Healing Power of Doing Good, 1991), as well as the 12-step principle that the best way to maintain one's own recovery is to help others with theirs. Follow-up can include bibliotherapy using books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy using films on the topics “Friends and Support Systems,” “Inspiration,” “Substance Abuse,” and “Values and Ethics” listed in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, published by John Wiley & Sons.

EXERCISE XI.C Helping Myself By Helping Others

Like the medical problems that cause it, chronic pain can be complicated. People living with serious injuries or illnesses must deal with not only the physical pain, but often with depression, anxiety, or uncertainty about the future. So we may find that although the pain medications and physical therapy prescribed by our health care providers help, they don't help enough, and they don't address the mental and emotional parts of our pain as well as the physical.

This is a problem people have known about for ages, and for just as long, people have discovered and rediscovered that we can find further relief for our suffering by helping others with their problems. In recent times there have been a number of scientific studies that confirm what many people have known for thousands of years, and explain how this works.

This exercise will guide you in learning about the benefits people gain in their own healing and quality of life by helping other people and exploring the ways you can take advantage of this in your own life.

1. One of the first benefits is a positive change in brain chemistry. To sum it up, the act of extending our caring to other people somehow increases the brain's levels of endorphins. These are natural chemicals that function to relieve pain, increase pleasure, lift our mood, and increase our feelings of energy and well-being. The same chemicals are responsible for what is called a “runner's high,”—a feeling of elation that long-distance runners often experience after they've reached a certain level of exhaustion—and for the temporary blocking of pain we may feel for a short time after an injury. Some have called this effect the “helper's high.” Do you know anyone who often does kind things for others and always seems unusually happy and healthy? Have you ever experienced this, and if so how?

_____

_____

_____

2. Another benefit, which seems like common sense once we think about it, is that doing good things improves the way we feel about ourselves. In Alcoholics Anonymous, there's a saying: “If you want to have self-esteem, do esteemable things.” Again, think of your own experiences and describe a time when you've done something unselfish and made someone else's life a bit better, and found that you felt better about yourself, too. Would this help when you're having trouble with depression, discouragement, or anxiety?

_____

_____

_____

3. Some other facts about human psychology seem to help explain the benefits of doing good things for other people. First, one of the main elements in depression—even suicide—is a feeling of isolation and lack of emotional connection to other people, a feeling that we don't matter to anyone else. It's easy to see that when one person reaches out and helps another, that sense of isolation and not mattering would be reduced in both of them. Another part of depression is a feeling of being powerless over what happens in our lives, and when we take action to make the world better for someone else we're proving to ourselves that we aren't powerless after all. Again, please think of your own experiences and briefly note a time when you might have felt depressed and found that your mood improved when you did something kind for another person, or when someone did something caring for you:

_____

_____

_____

4. Another fascinating piece of news from several research studies, on the effects of kindness and unselfishness, is that it actually improves the functioning of the immune system, helping us to resist illness, relieve the symptoms of chronic illnesses like arthritis, and speed recovery from injuries or surgeries. This news is clearly important for anyone living with chronic pain due to wounds, injuries, or illness. Are you interested in trying this out, and if so, how will you do so? What can you do to test it, and how can you keep track of your results?

_____

_____

_____

5. Here's another possible benefit. In the book Flow, a psychologist named Mihaly Csikszentmihalyi reports on a systematic study he completed to discover what makes people happy. He learned that we are happiest when we're doing something in which we get so absorbed that we forget about everything else for a while, and that the people who spend the most time in activities like that were the ones who were happiest overall. For a lot of us, that's how it feels when we help someone, especially if the help takes the form of sharing an activity we love with them. How could you try this out and see how it works for you?

_____

_____

_____

6. What other ideas do you have about ways you can put this idea to use and help yourself by helping others?

_____

_____

_____

_____

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.